Provider Demographics
NPI:1912710724
Name:EAGLE, GAVRIEL
Entity type:Individual
Prefix:
First Name:GAVRIEL
Middle Name:
Last Name:EAGLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 BURNET AVE APT 515
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2513
Mailing Address - Country:US
Mailing Address - Phone:443-788-0238
Mailing Address - Fax:
Practice Address - Street 1:830 EZZARD CHARLES DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-2525
Practice Address - Country:US
Practice Address - Phone:513-381-6672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406390-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health